cardiac study guide

142 Chapter 17 The Cardiovascular System

COMPLETION

Directions: Fill in the blanks to complete the statements.

l. Cardiac output depends on the heart , the amount of blood returning to the

__________ , the strength of , and the _

to the ejection of the blood. (404)

2. The left atrium receives blood from the pulmonary veins. (403)

3. equals the amount of blood pumped out of the heart each minute. (405)

4. is the condition where fibrous plaque with fatty deposits form in the inte-

rior layers of the arteries, causing narrowing. (406)

5. A is the difference between the apical and radial pulse rates when they

are counted at the same time. (420)

6. A weight gain of 3 lbs. or more in a period indicates fluid retention. (428)

7. The doctor orders furosemide (Lasix) oral liquid 20 mg PO every morning. The pharmacy delivers a

100 mL bottle of furosemide with a concentration of 40 mg/5 mL. How many mL should you give the

patient? mL (58)

SHORT ANSWER

Risk Factors and Assessment for Cardiac Disorders

Directions: Read the clinical scenario and answer the questions that follow.

Scenario: Mr. Blue is a 55-year-old construction worker. He reports that he was having difficulty performinghis job because of fatigue and shortness of breath. He tells you, "At first, I thought it was just stress and be-ing sort of overweight and just smoking, drinking, and eating too much. I decided to make an appointmentbecause my wife reminded me that we have heart disease and diabetes in the family."

l. You are collecting information about cardiac risk factors from Mr. Blue. What are four unmodifiable riskfactors related to the development of heart disease? (419)

a.

b.

c.

d.

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Chapter 17 The Cardiovascular System 143

2. List five modifiable risk factors that Mr. Blue has just reported in the scenario. What information can yougive him about modifying the factors that he has just mentioned? (409-410)

a.

b.

c.

d.

e.

3. Write at least five questions that you could ask Mr. Blue to get additional information about his shortnessof breath. (419)

a.

b.

c.

d.

e.

4. Listat least six things that should be included in the physical assessment of a patient like Mr. Blue, whomay have a cardiac disorder. (419)

a.

b.

c.

d.

e.

£

COMPLETION

Diagnostic Testing for Cardiac Disorders


1. Ultrasound Doppler flow studies are conducted to detect a in the vessel or to deter-

mine the of the vessel. (414)

2. Coronary angiography requires injection of a . (414)



3. The purpose of a venogram is to detect _

________________ . (414)

4. Explain to the patient that during impedance plethysmography, he may feel some discomfort related to

_____________________________ . (414)

5. Myoglobin level is performed to detect damage to the from a

________________ infarction. (416)

APPLICATION OF THE NURSING PROCESS

Changes with Aging

Directions: Read the scenario and provide the answers to the following questions.

Scenario: You are working in an extended care facility and Mrs. Wiabo is one of your elderly patients. Mrs.Wiabo is in stable condition, but she has several chronic health problems, including hypertension and oc-casional problems with fluid retention.

1. List at least six changes in the cardiovascular system associated with aging. (407-408)

a.

b.

c.

d.e.

f.

2. List at least five interventions (including assessments) to use with patients like Mrs. Wiabo who havefluid retention. (427-428)

a.

b.

c.

d.

e.f.

3. Which of the following nursing diagnoses is top priority for Mrs. Wiabo? (428)a. Chronic low self-esteem related to activity intoleranceb. Knowledge deficit related to disease process, medications, and self-carec. Imbalanced fluid volume, risk for, related to heart failured. Impaired social interaction related to being away from family

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4. Which of following is the best indicator that Mrs. Wiabo is not having any problems with fluid retention?(428)a. Urinates freely without pain or discomfort.b. No signs of pitting edema in the sacral area.c. Breath sounds are clear on auscultation.d. Shows no change in daily weight.

PRIORITY SETTING

Directions: Read the scenario and prioritize the steps to perform the procedure. (421)

Scenario: You are preparing to take a routine blood pressure on an ambulatory patient at a clinic. You havenever taken a blood pressure on this patient before and the patient does not remember his last blood pressurereading. You must use an ordinary manual blood pressure cuff (i.e., not a blood pressure machine). Put thefollowing steps in the correct order to perform the procedure.

a. Palpate the brachial artery.

b. Select the correct cuff size.

c. Center the bladder cuff over the brachial artery.

d. Listen until the sounds stop.

e. Report abnormal findings to the RN or MD.

f. Release cuff and wait 30-60 seconds.

g. Deflate cuff slowly and smoothly to obtain a correct diastolic reading.

h. Record your findings as soon as you obtain the reading.

1. Support the patient's arm, on which the cuff is placed, at heart level.

J. Ensure the patient has not smoked or had caffeine for the past 30 minutes.

k. Place the bell of your stethoscope over the brachial artery.

1. Tighten the screw clamp; inflate cuff 30 mm above the palpated pressure.

m. Obtain a palpated systolic blood pressure.

NCLEX-PN® EXAM REVIEW

Directions:Choose the best answer( s) for the following questions.


Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

1. The patient has diabetes. In order to lessen the risk of atherosclerosis, she should be advised to keep theblood sugar consistently below: (411)1. 80 mgldL.2. 110 mgldL.3. 120 mgldL.4. 200 mg/dL.

2. The nurse knows that in order to correctly perform the procedure for taking an apical pulse, the pulsemust be counted for: (420)1. 15 seconds.2. 30 seconds.3. 1 minute.4. 2 minutes.


3. The nurse has observed that the patient's jugular veins are prominent when the patient is in an uprightposition. This finding is associated with which of following cardiovascular disorders? (409)1. Congestive heart failure2. Cardiac dysrhythmia3. Angina pectoris4. Aortic aneurysm

4. When obtaining a patient's blood pressure, the nurse knows that if the blood pressure cuff is too narrow,the blood pressure will be: (421)1. unaffected by the equipment.2. falsely elevated.3. lower than expected.4. the same in both arms.

5. The nurse should report a positive Homans' sign because this may indicate: (422)1. intermittent claudication.2. arterial occlusion.3. edema and fluid retention.4. deep vein thrombosis.

6. The nurse is evaluating the patient's peripheral pulses. Which of following should be included in a rou-tine assessment? (420)1. Note rate and rhythm and mark the location.2. Take radial pulse on the patient's dominant side.3. Compare pulses bilaterally; note volume and strength.4. Elevate the extremity and check the pulse.

7. Which of the following is considered the best indicator of fluid buildup? (428)1. Pitting edema2. Decreased urinary output3. 3 lbs. weight gain in 24 hours4. Low serum sodium

8. The patient is experiencing acute anginal pain. Which group of drugs is the physician most likely to pre-scribe to treat this condition? (474)1. Cardiotonic and antilipemic2. Nitroglycerin and morphine sulfate3. Diuretic and ACE inhibitor4. Anxiolytic and antihypertensive

9. When planning nursing care, the nurse knows that many heart medications need to be given as close tothe prescribed time as possible. The best rationale for this practice is to: (474)1. complete shift duties in a timely fashion.2. prevent adverse response to medications.3. avoid confusing your elderly patients.4. maintain a steady blood level of the drug.

10. Which statement by the patient's wife indicates a need for further discussion about modifiable risk fac-tors for cardiac disorders? (410)1. "He can't lose weight because his parents were obese."2. "He could have up to two alcoholic drinks per day."3. "He could take a relaxation or meditation class for stress."4. "His blood pressure should be lower than 120/80."



11. The nurse is caring for a patient with Activity intolerance related to chronic heart failure. Which of thefollowing activities would be best to assign to the nursing assistant? (425)1. Observe the patient for fatigue and shortness of breath when ambulating.2. Assist the patient with limited morning hygiene such as washing face and brushing teeth.3. Explain to the family why taking long walks on the hospital grounds is not feasible at this time.4. Obtaining assistive devices that would help the patient to conserve energy and strength.

CRITICAL THINKING ACTIVITIES

Scenario: Mrs. Reno is an elderly female who comes to the clinic after experiencing some mild chest pain.She is accompanied by her husband. You are attempting to perform the PQRST for pain assessment. Mr.Reno keeps answering for his wife, even though she is alert and oriented and seems capable of answering forherself. She sits quietly and smiles at you, but allows her husband to do the talking despite your best efforts.

1. What is the PQRST pain assessment? (420) _

2. Could Mr. Reno provide correct answers to any of the PQRST pain assessment questions? If so, whichquestions might he be able to accurately answer? (420)

3. What are your personal feelings about this type of situation? _

4. What factors (i.e., cultural, social, age, psychological) might help to explain Mr. and Mrs. Reno's behav-ior?


Care of Patients withHypertension and PeripheralVascular Disease

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COMPLETION

Hypertension


1. Hypertension can indirectly affect the heart by causing changes in the

blood vessels. (434)

2. The three organs most likely to be damaged by a consistently high blood pressure are the

______ , ,and . (435)

3. Hypertension can be secondary to and symptomatic of other diseases, such as those affecting the blood

supply to the and . (434)

4. Nicotine has a major impact on blood vessels and blood pressure by producing

__________ . (434)

5. Hypertension is diagnosed when an elevated blood pressure is taken at least and aver-

aged on two different occasions, weeks apart. (433)

6. The physician examines blood vessels in the to detect signs of persistent

hypertension. (435)

SHORT ANSWER

Hypertension

Directions: Read the following scenario and answer the questions that follow.

Scenario: You are participating in a health fair that includes blood pressure screening for hypertension anddispensing information about healthy lifestyle habits. In addition, interested people are inquiring about howto recognize potential symptoms and various types of treatment, including medication for hypertension.

Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 151

152 Chapter 18 Care of Patients with Hypertension and Peripheral Vascular Disease

1. List four specific ways in which a person with mild hypertension might help reduce his blood pressurewithout taking any antihypertensive drugs. (438)

a.

b.c.

d.

2. List subjective symptoms and objective data that would be significant in the assessment of a patient withhypertension. (434-435)

a. Subjective symptoms:

b. Objective data: _

3. The target is to maintain a blood pressure at or below . (436)

4. List specific patient information in each of the following areas: self-care and keeping blood pressure un-der control.

a. Limiting sodium intake: (440) _

b. Limiting caffeine and nicotine intake: (440) _

5. List three drug classifications that may be used in the treatment of hypertension and give an example ofeach classification. (437)


Chapter 18 Care of Patients with Hypertension and Peripheral Vascular Disease 153

APPLICATION OFTHE NURSING PROCESS

Caring for a Patient with Arterial Insufficiency

Directions: Read the scenario and provide the answers to the following questions.

Scenario: Mrs. Rodriguez reports that she recently joined a fitness center. She noticed leg cramps when shestarted jogging on the treadmill, but states that the cramps resolved within several minutes after she stoppedjogging. She denies pain or discomfort if walking at a regular pace. The physician tells her that she may have amild arterial insufficiency that can be treated with exercise and possible medication if her symptoms worsen.

1. List three contributing factors in the development of arterial insufficiency. (442)

a.

b.

c.

2. List five signs and symptoms that would indicate diminished arterial blood flow in the peripheral vessels.(442)

a.

b.

c.

d.

e.

3. You are assessing Mrs. Rodriguez and checking the "5 Ps." What are the "5 Ps"? (442)

a.

b.

c.

d.

e.

4. The doctor tells Mrs. Rodriguez that she has intermittent claudication. You explain to her that intermit-tent claudication is characterized by: (442)a. edema of the lower legs.b. cramping pain that eases with rest.c. warm, reddened areas on the lower legs.d. pale, cold feet.




5. What are three major nursing goals for patients like Mrs. Rodriguez? (444-445)

a.

b.

c.

6. List five self-care measures that could be taught to Mrs. Rodriguez to help her cope with impaired pe-ripheral circulation and to avoid stasis ulcers and possibly gangrene. (445)

a.

b.

c.

d.

e.

7. Write evaluation criteria that would indicate that the interventions are successful and the expected out-come is being met for Mrs. Rodriguez for the following patient goal: (446)

Patient will verbalize at least three self-care measures to protect tissues from injury due to decreased arte-rial flow, after patient teaching session.

a.

b.

c.

PRIORITY SETTING

Directions: Read the scenario and prioritize as appropriate.

Scenario: You are caring for Mr. Ebuto, who has been admitted for a diagnosis of deep vein thrombosis, andhe is currently on bed rest and receiving IV heparin. He has anti-embolism (TED) hose in place, with sequen-tial compression devices (SCDs).

1. In the morning, you enter Mr. Ebuto's room and you find that the IV heparin has been turned off. Mr.Ebuto tells you that "somebody came in during the evening and took the IV pump away."What is yourpriority action? (445-446)a. Quickly obtain a new pump and restart the heparin.b. Report the incident to the charge nurse.c. Obtain a physician's order for partial thromboplastin time (PTT) and activated partial thromboplas-

tin time (aPTT).d. Check the physician's orders to see if heparin was discontinued.


2. Mr. Ebuto is lying in bed. His TED hose are in place, but the SCDs are at the bottom of the bed. He tellsyou that the new nursing assistant removed them during morning hygiene. What is your priority action?(445-446)a. Replace the SCDs; talk to the nursing assistant about the purpose of SCDs.b. Instruct the nursing assistant on how to replace the SCDs.c. Teach the patient how to replace them and to call for assistance as needed.d. Report the incident to the nursing educator and the charge nurse.

3. While you are assessing Mr. Ebuto after lunch, you note several abnormal findings. Which assessmentfinding is the priority? (445-446)a. Bleeding of the gums and petechiaeb. Dyspnea and tachypneac. Increasing pain in the calfd. Pitting edema of the affected limb

4. Based on your determination of the priority assessment finding (#3 above), which action will you takefirst? (445-446)a. Check the PTT and aPTT results.b. Obtain equipment to give oxygen.c. Assess the quality/onset of calf pain.d. Measure the circumference of the limb.

NCLEX-PN@ EXAM REVIEW

Directions: Choose the best answer(s) for the following questions.

1. When assessing a patient for possible peripheral vascular disease (PVD), which one of the following is aprime contributing factor? (441)1. History of structural defects in the arteries2. History of excessive alcohol intake3. History of inflammation of the veins4. History of cigarette smoking

2. A nursing intervention that is important in the care of a patient with a deep vein thrombosis is to assessfor complications of: (445)1. infection.2. gangrene.3. embolus.4. severe pain.

3. The most common cause of peripheral arterial disorders is: (441)1. arteriosclerosis.2. a sedentary lifestyle.3. rheumatic fever.4. hypertension.

4. The nurse should teach patients with chronic venous stasis to sit with their legs: (446)1. crossed.2. straight.3. elevated.4. dependent.



5. The nurse is teaching the patient about dietary sources of potassium. Which of following food groups isthe best dietary source for potassium? (438)1. Milk, cheese, and eggs2. Beef, turkey, and tomatoes3. Whole grain bread and cereals4. Lettuce, cabbage, and onions

6. An acute sign of inadequate blood supply to the feet is: (442)1. excessive hair growth.2. reddened, warm skin.3. brittle, thick toenails.4. pale, cool, mottled skin.

7. The patient is taking digoxin and a thiazide diuretic. This combination of medications increases the riskfor cardiac dysrthymias related to: (438-439)1. hypokalemia.2. hypotension.3. hyperkalemia.4. hypertension.

8. When evaluating continuous intravenous heparin therapy for a patient with a deep vein thrombosis, thenurse assesses for: (457)1. the degree of discomfort the patient is experiencing.2. the results of the prothrombin time laboratory test.3. signs of internal and external bleeding.4. nausea and anorexia due to the medication.

9. An important safety factor in planning the care for a patient with a deep vein thrombosis is to: (457)1. apply heat packs to the affected leg.2. handle the leg gently to prevent dislodgment of the clot.3. keep the leg straight and at hip level to prevent edema.4. maintain the heparin drip so that the clotting time is three times that of the control.

10. Upon assessment, signs of abdominal aortic aneurysm include: (448)1. higher blood pressure in the legs than in the arms.2. bounding popliteal pulses and warm, pink skin.3. an enlarged abdomen with decreased bowel sounds.4. back pain and possibly a visible pulsation of the abdomen.

11. Which of following assessment findings would be most likely to be found in the documentation of apatient admitted for a cerebral aneurysm? (448)1. Pressure sensation in the back2. Difficulty breathing3. Visible pulsation of the abdomen4. Impaired speech and confusion

12. When providing postoperative care for a patient following a carotid endarterectomy, which of followingassessment findings is the priority concern? (444)1. Increasing hoarseness2. Loss of appetite3. Presence of a bruit4. Nausea



13. When a patient is receiving intravenous heparin, the diagnostic test performed to monitor its effective-ness is: (457)1. serum heparin level.2. activated partial thromboplastin time or partial thromboplastin time.3. platelet aggregation test.4. prothrombin time and International Normalized Ratio value.


Scenario: You are working with several patients who are to receive heparin. Perform the following math cal-culations to determine the correct dose or to verify the setting of the IV infusion. (58)

1. The patient is on an IV heparin drip for treatment of a deep vein thrombosis. The IV heparin bag (25,000units/250 mL) is in place with a pump. It is set to infuse at 8 mLihour. The physician has ordered 800units/hour. Is the pump setting correct or incorrect? _

2. The doctor orders 5000 units SQ heparin for postoperative prophylaxis. The pharmacy delivers a 10 mLvial of heparin sodium (5000 units/mL). How many mL should you give? _

3. The pharmacy delivers a premixed bag of heparin 25,000 units/500 mL. How many units are in 1 mL?

4. The patient is on an IV heparin drip. The IV heparin bag (10,000 unitsl100 mL) is in place with a pump.It is set to infuse at 10 mLihour. The physician has ordered 1000 units/hour. Is the pump setting corrector incorrect? _

STEPS TOWARD BETTER COMMUNICATION

VOCABULARY BUILDING GLOSSARY

Termbar' orecep'tor

Pronunciationbar 0 re cep' tor

Definitionsensory receptor stimulated by changes inpressurepain in leg muscles, limping or lamenesshanging downnot able to perform the function or jobinsufficient blood in a parton the outer edgesmade more powerful (two drugs may reacttogether to be more powerful)temporary loss of consciousness, faintingtwisted, windingthickness of a liquiddoes not follow instructionssymptoms that the patient is unable toobserve or feelresult of a treatment or medication in addi-tion to the intended effect

claudica'tiondepen'dentincom'petentischemiaperiph' eralpoten'tiated

klaw di kay' shunde pen'dentin com'pe tentis kee' me apa rif' ah ralpo ten' shee a ted

synco'petor'tuousviscos'itynoncompli'ant"silent" symptoms

sing ko' peetor' tu ousvis cos' i tynon com pli'ant

side effect



COMPLETION

Directions: Fill in the blanks with the appropriate words from the Vocabulary Building Glossary to complete thestatements.

1. When taking a blood pressure, the arm should be at the level of the heart rather than _

2. When the nurse assessed the patient's arm before trying to start an intravenous infusion, the veins werefoundtobe _

3. The patient who is polycythemic has increased blood _

4. The patient with swollen, dusky feet probably has vascular disease.

5. Many hypertensive patients are with therapy because they do not no-

tice any symptoms of high blood pressure.

6. The patient who has peripheral arterial vascular disease often experiences _

__________ when walking.

7. A signals the brain about changes in blood pressure.

8. When a vein develops varicosities, it becomes _

9. The effect on blood pressure is when an antihypertensive is com-

bined with a diuretic medication.

10. Hypertension often causes only _

11. When a thrombosis occurs in a vessel, develops distal to it.

12. Carotid occlusion may cause in the patient.

13. Hypokalemia is a of many diuretics.

WORD ATTACK SKILLS

Combining Forms

These combining forms are used in words found in Chapter 18 of the textbook:

angi/o vessel, channel

vaso vessel, duct

sclero

ven/o

thromb/o

stal

stenl

hard, hardening

vem

blood clot

make stand, stop

narrow, compressed


Care of Patients with CardiacDisorders

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COMPLETION

Cardiac Disorders


1. A(n) is used for patients who have repeated episodes

of life-threatening ventricular fibrillation or cardiac asystole (arrest). (479)

2. The signs and symptoms of mitral valve disorders are , _

___________ , and . (483)

3. is the most common cause of cardiac inflammation in chil--------------------dren who do not have congenital cardiac abnormalities. (479)

4. For women, the main symptom of a heart attack may be diffuse chest pain, which may be mistaken for

___________________________ . (463)

5. Valve surgery is performed on the dysfunctional valve when the person's _

_________ . (482)

6. A sign of pericarditis that can be heard during auscultation of the heart is _

______________ . (481)

7. ____________ imbalances may cause serious cardiac dysrhythmias. (470)


Care of the Patient with Congestive Heart Failure

Directions:Read the scenario and provide the answers to the following questions. (467-468)

Scenario: Mrs. Santo, age 63, has moderate congestive heart failure. She has been admitted to the hospital forcomplaints of severe dyspnea, generalized edema, weakness, and fatigue. Her physician has ordered bedrest,up to bathroom PRN, in chair for 30 minutes three times a day, and oxygen PRN for dyspnea. Mrs. Santo isalso receiving digoxin (Lanoxin) 0.250 mg daily, hydrochlorothiazide (a diuretic), and Isordil (a venous dila-tor). Her daily sodium intake is limited to 1000 mg.

Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 161

162 Chapter 19 Care of Patients with Cardiac Disorders

1. List objective and subjective data that would help assess Mrs. Santo's status with regard to dyspnea,edema, and peripheral circulation.

a. Dyspnea: Subjective data:

Objective data: _

b. Edema: Subjective data: _

Objective data: _

c. Peripheral circulation: Subjective data: _

Objective data: _

2. Upon admission, which of the following nursing diagnoses is a priority for Mrs. Santos? (467)a. Activity intolerance related to decreased perfusionb. Risk for injury related to complications of CHFc. Decreased cardiac output related to ineffective cardiac muscled. Dyspnea, gas exchange, impaired related to fluid in lung tissue

3. List three nursing actions you would expect to find on Mrs. Santo's nursing care plan during her hospi-talization. (468-469)

a.

b.

c.

4. An appropriate task to assign to the nursing assistant would be to:a. ask the patient if she needs extra pillows to prevent orthopnea.b. assist the patient to turn every 1-2 hours.c. determine if Mrs. Santo needs partial or full assistance with ADLs.d. check the sacral area for edema and skin breakdown.

5. Mrs. Santo lives with her husband, daughter, and four grandchildren. Before she is discharged, shewill need instruction in self-care and her family will need instruction so they can give her support andencouragement. She has been told by her physician to walk at least 1 mile per day, to continue takingher digoxin and diuretic, to stay on her sodium-limited diet, and to lose 25 pounds. Identify at least fivepoints that should be included in the teaching plan for Mrs. Santo and her family so that she can remainrelatively symptom-free once she returns home. (467)


Chapter 19 Care of Patients with Cardiac Disorders 163

a.

b.

c.

d.

e.

6. Which of the following statements by Mrs. Santos indicates that she understands the implications ofdigoxin toxicity? (474)a. "I will report nausea, vomiting, and anorexia."b. "I can eat bananas and citrus to counteract side effects."c. "I can skip a dose if I experience side effects."d. "I should carry digoxin immune (Digifab) as an antidote."

7. Mrs. Santo is prescribed digoxin 0.250 mg daily. The pharmacy delivers a bottle with 50 Lanoxin tablets;125 mcg/tablet. Has the pharmacy delivered the correct medication? If so, how manytablets should Mrs. Santo take? _

PRIORITY SETTING


Scenario: You are caring for Mr. Ducas, an elderly gentleman who was admitted for congestive heart failure.During the morning assessment you find that his condition seems to have deteriorated compared to yester-day.You find several abnormalities. (467-468)

1. Which of the following assessment findings is the priority?a. Absent peripheral pulsesb. Frothy sputum and orthopneac. Confusion and irritabilityd. Fever and tachycardia

2. Based on your assessment findings, Mr. Ducas appears to be having complications due to congestiveheart failure and he is exhibiting the signs and symptoms of acute pulmonary edema. Which of followingis the priority action? (470)a. Immediately report your findings to the RN/physician.b. Check for standing orders for oxygen and morphine.c. Place the patient in a high Fowler's position.d. Stay with the patient until the code team arrives.



1. Which of the following should the nurse expect to note with a diagnosis of atrial fibrillation? (472)1. Low blood pressure2. Headaches and fatigue3. Feelings of palpitations4. An irregular pulse rate



2. Medications that the nurse might administer to patient with atrial fibrillation include: (475)1. digoxin and Coumadin.2. potassium and Tenormin.3. lidocaine and calcium.4. aspirin and Isordil.

3. A patient is receiving digoxin. To evaluate the effectiveness of the medication, the nurse would check:(474)1. pulse rate and breath sounds.2. digoxin and potassium laboratory values.3. blood pressure and respirations.4. weight loss and appetite.

4. Early signs of congestive heart failure include: (467)1. weight gain and dyspnea on exertion.2. a wet cough and severely swollen ankles.3. cyanosis, fatigue, and dyspnea.4. an irregular pulse rate and elevated blood pressure.

5. When the nurse is administering digoxin, she should always first: (474)1. assess the amount of weight gain or loss.2. question the patient about fatigue and dizziness.3. check for signs of hypokalemia.4. be certain that the patient has a full stomach.

6. A patient with atrial fibrillation is taking an oral anticoagulant. The patient should be taught to have afollow-up appointment for: (477)1. prothrombin time (PT) and international normalized ratio (INR).2. partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT).3. complete blood count (CBC) and hematocrit (Hct).4. cardiac enzymes.

7. A patient who has modifiable risk factors must be taught to: (466)1. eat regular meals, drink sufficient amounts of water, and avoid caffeine.2. exercise 20 minutes per day at least twice a week.3. limit alcohol consumption to two drinks per week.4. keep blood pressure < 120/80 mm Hg.

8. The postoperative care of a patient who has received a permanent pacemaker includes which of the fol-lowing? (Select all that apply.) (482)1. Monitor heart rate and rhythm and check vital signs.2. Perform dressing changes and care for the insertion site.3. Check peripheral pulses proximal to the insertion sites.4. Check level of consciousness frequently in the immediate postoperative period.5. Teach the patient to count his pulse for a full minute.6. Teach patient that full recovery takes about 12 weeks.

9. When planning care for a patient who needs dietary modifications to improve heart health, the nursewould include teaching to: (484)1. include 12 grams of fiber in diet each day.2. include foods that contain trans-fats.3. avoid drinking any coffee or iced beverages.4. eat six or more servings of whole grain products each day.




Scenario

You are assigned to work on a telemetry unit. There is a telemetry technician who is monitoring the patientsfrom a remote location; however, there is a monitor at the nurse's station that is displaying the EKG rhythmfor each patient. Although the technician will call if he notes a problem, the nurses are responsible to also beable to recognize arrhythmias and respond accordingly.

Directions: Identify the EKG rhythms and answer the related questions. (471-473)

1. Rhythm strip #1

,-ll j .-- r - T-- T'----,-,-~--,-----.---

;+ ,+1- -1- l~i1-1-1- ~lL-i---i ft -+ -+-. -

-+ t,

I,r

~ -+- ----- ..-J

a. Identify this rhythm. _

b. What is the appropriate action to take? _

2. Rhythm strip # 2


b. Explain why patients who have this arrhythmia may be on Coumadin.



fI

3. Rhythm strip # 3

r0-"--[, I

a. Identify this rhythm.

b. What is the appropriate action to take? _

4. Rhythm strip # 4


b. What are two medical treatments that could be ordered to treat this arrhythmia?

Copyright © 2009 by Saunders, an imprint of Elsevier lnc.


5. Rhythm strip # 5

--;}j

u


b. Explain in your own words why this rhythm may cause your patient to have a change in mentalstatus.

STEPS TOWARD BETTER COMMUNICATION

VOCABULARY BUILDING GLOSSARY

Term Pronunciation Definition

involving the puncture or cutting of theskin, or putting an instrument into thebody

. ,.inva srve. , .m va srve

telem'etry te lem' e try

engorg'ed en gorj' d

bloated blo'tid

quiver kwiv' er

hyper' trophy hi per' tro fee

cardiomyop' athy kar dee 0 mi op' ah thee

a'trioventric'ular a' tree 0 ven trik' u lar

fib'rilla'tion fib' ri la' shun

intersti'tial in ter stish' al

measuring data with radio waves and elec-tronic equipment

filled to the limit; swollen

to be swollen, larger than normal

to vibrate with a small, rapid motion

extra growth, thickened

disorder of heart muscle that prevents itfrom pumping effectively

relating to an atrium and ventricle of theheart

small, rapid, irregular muscle contractions;quivering

spaces in the tissue between the cells




COMPLETION

Directions: Fill in the blanks with the appropriate words from the Vocabulary Building Glossary to complete thestatements.

1. During ventricular fibrillation, the heart _

2. The patient whose heart rate is being monitored is hooked up to a unit

that transmits the EKG pattern to the monitor in the nurse's station.

3. __________ or increased growth of left ventricle muscle may be hereditary.

4. When congestive heart failure occurs, the lung vessels become with blood and fluid leaks

into the interstitial spaces.

5. A cardiac catheterization is a(n) type of test.

6. The major problems exhibited by patients with are heart failure and dysrhythmias.

7. If the SA node fails to pace the heart, the node may take over.

8. Patients can be treated for chronic atrial , but ventricular

____________ is life-threatening.

9. The patient who experiences right-sided congestive heart failure develops a swollen liver and may feel

10. Edema results if body fluids in the intravascular fluid compartment begin to leak into the

________________ compartment.

WORD ATTACK SKILLS

Combining Forms

Here are some important combining forms found in this chapter:

cardi/o heart

my/o

sin/o

vas/o

muscle

a space or channel

vessel

end/o inside

COMMUNICATION EXERCISE

You are advising Mrs. Perryman who has complained of pain in her legs due to varicose veins. She also hashigh blood pressure. (Practice the dialogue with a partner.)

Mrs. Perryman: My legs hurt-and look at these ugly varicose veins! My feet and legs hurt at the end ofthe day. They are swollen. And I get so tired!

Care of Patients with CoronaryArtery Disease and CardiacSurgery

• fJ " I J ,,, fJ Go to http://evolve.elsevier.com/deWit for additional activities and exercises.

TERMINOLOGY

Directions: Define the following terms.

Angina pectoris: (492) ~ _

Coronary insufficiency: (488) _

Drug-eluting stent: (498) _

Myocardial infarction: (493) _

Necrosis: (493) _

Ischemia: (493) _

COMPLETION


1. As the coronary vessels narrow, the patient may experience symptoms of ischemia such as

_______ and . (489)

2. is the major contributing factor to the formation of

this fatty material that contributes to the process of atherosclerosis. (488)

3. Women are more likely to experience heart attacks after reaching ; however,

poor habits, lifestyle, and levels of stress

contribute to development of cardiovascular disease earlier in life. (493)

4. Any activity that increases the heart's workload increases its need for . (489)

5. The prognosis of the patient who suffers an acute myocardial infarction (MI) depends on the

__________ of the artery obstructed, the location, and the _

of heart tissue that is damaged. (493)

Copyright © 2009 by Saunders, an imprint of Elsevier lnc. 171

172 Chapter 20 Care of Patients with Coronary Artery Disease and Cardiac Surgery

6. Another treatment method for occlusion of a coronary artery other than coronary artery bypass graft is

the procedure called . (502)

7. It is important to stress to the patient that she has over her rehabilitation and

prognosis. (499)

8. A thrombolytic agent must be administered within hours of experiencing the symptoms

of MI, in order to prevent or decrease damage to the heart muscle. (407)

9. After receiving a heart transplant, the patient must take for life. (505)

10. Two constant potential complications that the heart transplant patient must deal with are____________________ and .~O~

11. The doctor orders IV fluid for a postoperative patient to infuse at 125 mL/hour. The drop factor is 10

gtts/mL. What is the drip rate? (58)

TABLE ACTIVITY

Cardiac Surgeries

Directions: Fill in the blocks below with the type of surgery that matches the description. The first block has beendone for you.

Type of Surgery Descriptioncoronary artery bypass graft (CABG) surgery bypasses the blocked artery, replacing it with sections of a vein

or artery taken from another part of the patient's body

does not require stopping the heart's activity, and therefore does notrequire using the heart-lung machine (501)

is invasive and similar to the procedure used for cardiaccatheterization where a catheter is introduced through the femoralvessel (502)

part of the latissimus dorsi muscle is detached from its naturalposition and brought around to the front of the body (504)

can be accomplished with a mechanical or biological device (504)

performed for selected patients who have end-stage left ventricularfailure resulting from cardiomyopathy (505)


Chapter 20 Care of Patients with Coronary Artery Disease and Cardiac Surgery 173


Care of a Patient with Angina Pectoris

Directions: Provide the answer to the following questions.

1. What other information from Mr. Locke's history could be helpful in assessing his cardiovascular status?(493)

Scenario: Mr. Locke, age 55, is admitted to the hospital with chest pains. Over the past year, he has graduallybecome more fatigued and uncomfortable whenever he exerts himself. His admitting diagnosis is possibleangina pectoris.

a.

b.

c.

d.

2. Two nursing diagnoses on Mr. Locke's nursing care plan are Pain and Knowledge deficit. List three spe-cific nursing interventions appropriate for each nursing diagnosis.

Pain related to decreased coronary artery circulation: (494)

a.

b.

c.

Knowledge deficit related to self-care: (495)

a.

b.

c.

3. Which of the following objective data indicates that Mr. Locke's level of physical activity is appropriate tohis recovery?a. Patient asks for assistance when he becomes fatigued.b. Patient's heart rate and respiratory rate are stable after ambulation.c. Patient's activity is observed by the physical therapist.d. Family tells you that he is walking like he used to prior to hospitalization.


174 Chapter 20 Care of Patients with Coronary Artery Disease and Cardiac Surgery

PRIORITY SETTING


You are working in an extended care facility. Mr. Ido is walking down the hall and reports to you that he ishaving angina. He has a PRN order for sublingual nitroglycerine and he asks you to assist him with the medi-cation that is on his bedside table. Prioritize the steps in administering the nitroglycerine. (493)

a. If the pain has not eased or if BP increases, administer second tablet.

b. Give one tablet, placed under the tongue, wait 5 minutes.

c. Notify the physician regarding pain.

d. Assist the patient to lie in bed.

e. Wait 5 minutes, reassess pain.

f. Obtain a baseline BP.

g. Reassess pain and recheck BP.

h. Administer a third tablet if pain persists.

1. Recheck BP; it should have decreased.



1. The risk factors that lead to a higher incidence of atherosclerosis include which of the following? (Selectall that apply.) (488-489)1. High levels of high-density lipoproteins2. Cigarette smoking3. A history of hypertension and diabetes mellitus4. Age (> age 40), gender, and race5. Women on oral contraceptives or estrogen replacement therapy

2. Which of the following is the most significant in diagnosing damage to the myocardium? (496)1. Elevated level of troponin2. Elevated level of creatine phosphokinase (CPK)3. Elevated level of creatine phosphokinase-MB (CK-MB)4. Elevated level of lactate dehydrogenase (LDH)

3. The patient is taking lovastatin (Mevacor) for treatment of hypercholesterolemia. The patient shouldhave follow-up because of the potential for: (490)1. nephrotoxcity.2. cardiotoxicity.3. hepatotoxicity.4. ototoxicity.

4. The patient presents in the emergency department with severe chest pain. Which of the following arelikely to be prescribed during the initial emergency care? (497)1. Morphine, oxygen, nitrates, aspirin2. Beta-blockers, clopidogrel (Plavix)3. Simvastatin (Lipitor), lorazepam (Ativan)4. Oxygen, dobutamine (Dobutrex)


Chapter 20 Care of Patients with Coronary Artery Disease and Cardiac Surgery 175

5. Which of the following statements by the patient indicates a need for additional teaching about taking hisnitroglycerine? (493)1. "I should try to sit or lie down before I take a tablet."2. "If I get a headache, I should not take any more."3. "I can take up to three tablets before I call my doctor."4. "The tablets should be stored in a dark bottle."

6. A patient who has had an acute myocardial infarction may be prescribed a stool softener. The purpose ofthe stool softener in this case is to: (497)1. counteract the effects of prolonged bedrest.2. conserve energy associated with walking to toilet.3. counteract the side effects of medications.4. decrease the risk of bradycardia associated with straining.

7. Which of the following is a contraindication for thrombolytic therapy, such as t-PA (Activase)? (497)1. History of hypertension2. History of hemorrhagic stroke3. Symptom onset within past 12 hours4. Intraspinal surgery during childhood

8. The patient is admitted for an acute MI. Which of the following symptoms or findings is expected within24 hours after the attack? (497)1. Continuous, dull substernal chest pain2. A slightly elevated temperature3. An abnormal electrocardiogram4. A decline in the level of LDH

9. The nurse knows that there are several types of angina. Which of the following is considered the mosturgent and in need of immediate attention? (492)1. Exertional angina2. Variant angina3. Vasospastic angina4. Unstable angina

10. For a patient who is taking a statin drug, an important teaching point to include would be to: (490)1. report muscle tenderness or pain that persists for more than a few days.2. increase consumption of grapefruit juice to supply K+.3. have follow-up appointments to monitor platelet count.4. discontinue medication when the target weight goal is met.

11. One of the major goals of cardiac rehabilitation is to: (499-500)1. assist the patient to return to previous level of functioning.2. ensure that the patient can perform activities of daily living.3. increase activity based on individual progress and needs.4. teach the patient how to resume sexual relations.

12. There are several patients on a busy cardiac rehabilitation unit who need assistance. Which task would beappropriate to assign to the nursing assistant? (4)1. Find out why a depressed patient is not doing his physical therapy.2. Answer a family member's question about how to contact a local support group.3. Escort a patient who has been discharged home to his wife's car.4. Listen to a patient who is complaining about the bad hospital food.


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